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RQIA Enforcement Procedures · PDF file Page 3 of 30 Definitions and Abbreviations RQIA – Regulation and Quality Improvement Authority. DHSSPS – Department of Health and Social

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Text of RQIA Enforcement Procedures · PDF file Page 3 of 30 Definitions and Abbreviations RQIA...

  • RQIA Enforcement Procedures (Document 2 in a Suite of 6)

    Effective From: April 2017

    Date of Issue: April 2017

    Date of Review: April 2019

  • Page 1 of 30

    Contents Page

    Definitions and Abbreviations 3

    1. Introduction 5

    2. Principles 5

    3. The Legislative Framework 5 Unregistered Establishment or Agency 6

    4. Enforcement Process 6 Enforcement Actions 7 Issuing and Serving Enforcement Documents 8 Communication with Stakeholders 9

    5. Enforcement Decision Making (EDM) 9

    6. Serious Concerns (SC) 10 Serious Concerns - Meeting Preparation 10 Serious Concerns - Meeting 10 Non-Attendance 11 Serious Concerns - Meeting Outcomes 11

    7. Improvement Notice (IN) 11 Intention to Serve an Improvement Notice - Meeting

    Preparation 12

    Intention to Serve an Improvement Notice - Meeting 12 Non-Attendance 13 Not Serving an Improvement Notice 13 Serving an Improvement Notice 13 Compliance Assessment 14 Compliance Achieved 14 Compliance Not Achieved 15

    Enforcement Relating to Part III Establishment and Agencies Only 16

    8. Failure to Comply Notice (FTC) 16 Intention to Serve a Failure to Comply Notice - Meeting

    Preparation 16

    Intention to Serve a Failure to Comply Notice - Meeting 17 Non-Attendance 17 Not Serving a Failure to Comply Notice 18 Serving a Failure to Comply Notice 18 Compliance Assessment 19 Compliance Achieved 19 Compliance Not Achieved 19

    9. Notice of Proposal (NOP) 20 Intention to Serve a Notice of Proposal - Meeting Preparation 21 Intention to Serve a Notice of Proposal - Meeting 21 Non-Attendance 22 Not Serving a Notice of Proposal 22 Serving a Notice of Proposal 22 Representation 23 Not Adopting a Proposal 23

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    10. Notice of Decision (NOD) 24 Serving a Notice of Decision 25 Appeal to the Care Tribunal 25 When does RQIA’s Decision Take Effect? 26 Removal or Variation of Imposed Conditions 27

    11. Urgent Procedure 27 Appeal to the Care Tribunal 29

    12. Other Actions RQIA May Take in Respect to Services Not Falling Under Part III of the 2003 Order

    30

    List of Appendices

    Appendix 1 RQIA’s Stakeholders

    Appendix 2 RQIA’s Quality Improvement Plan

    Appendix 3 Associated Templates

    3.1 Unregistered Establishments or Agencies Templates 3.2 Serious Concerns Templates 3.3 Improvement Notices Templates 3.4 Failure to Comply Templates 3.5 Notice of Proposal Templates 3.6 Notice of Decision Templates 3.7 Urgent Procedure Templates

    Appendix 4 Enforcement Process Flow Charts

    4.1 Enforcement Decision Making Procedure 4.2 Serious Concerns Procedure 4.3 Improvement Notice Procedure

    4.3.1 Extension Improvement Notice Procedure 4.4 Failure to Comply Procedures

    4.4.1 Extension Failure to Comply Procedure 4.5 Notice of Proposal and Notice of Decision Procedure to Cancel

    Registration 4.6 Notice of Proposal and Notice of Decision to Refuse an

    Application for Registration 4.7 Notice of Proposal and Notice of Decision Procedure to Grant

    an Application Subject to any Conditions Not Agreed in Writing, To Vary or Remove any Condition, To Impose Any Additional Condition on Registration

    4.8 Urgent Procedure

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    Definitions and Abbreviations RQIA – Regulation and Quality Improvement Authority. DHSSPS – Department of Health and Social Services and Public Safety, now called Department of Health (DoH). DoH – Department of Health, which is the new name for the DHSSPS. 2003 Order – The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003, which is the legislation that sets out RQIA’s statutory responsibilities and powers. Regulations – created by the DHSSPS (now known as the DoH), these documents specify the regulations that each type of establishment or agency must operate within. Standards – prepared and published by the DHSSPS (now known as the DoH), these documents identify the acceptable minimum standard for each type of establishment or agency. QIP – Quality Improvement Plan is a section within the inspection report that states all areas for compliance with regulations and/or standards. The Registered Person/Trust’s Responsible Individual is required to complete the QIP, setting out the actions taken/to be taken in accordance with timescales determined by RQIA. Registered Manager – individual registered with RQIA to manage an establishment or agency. Registered Provider – an individual, an individual in partnership with others, a partnership or an organisation registered to carry on an establishment or agency. Registered Person/s – the Registered Provider or the Registered Manager in respect of an establishment or agency. Responsible Individual – an individual e.g. a director, a manager, a secretary, or other officer of an organisation, who is responsible for supervising the management of an establishment or agency. Trust’s Responsible Individual – the Chief Executive in respect of a trust. EDM – An internal ‘Enforcement Decision Making’ meeting that takes place at key decision stages within RQIA’s enforcement procedure. IN – an ‘Improvement Notice’ which may be served when there have been failings to comply with minimum standards. FTC – a ‘Failure to Comply Notice’, which may be served against failings to comply with regulations.

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    NOP – a ‘Notice of Proposal’ may be served when RQIA are proposing to refuse an application, cancel registration, vary, remove, or impose conditions on registration. NOD – a ‘Notice of Decision’ may be served if RQIA have not received or upheld representations regarding a NOP within the specified timescale. ERP – An internal ‘Enforcement Review Panel’ meeting may be convened to consider any representations made to RQIA’s Chief Executive Officer (CEO) in respect of Improvement Notice/s or Failure to Comply Notice/s. See ‘RQIA Enforcement Review Panel (ERP) Procedures in Respect of Improvement Notice/s’ and ‘RQIA Enforcement Review Panel (ERP) Procedures in Respect of Failure to Comply Notice/s’ for more information. DMP – An internal ‘Decision Making Panel’ meeting may be convened to consider any representation made to RQIA’s CEO in respect of Notice/s of Proposal. When RQIA has issued a NOP to refuse or cancel registration of an establishment or agency, a DMP will always be convened. A DMP will also always be convened:

     when RQIA wish to make an application to a Lay Magistrate for an order using urgent procedures

     when representation is received regarding a NOP to vary, remove or impose an additional condition

    See ‘RQIA’s Decision Making Panel (DMP) Procedures in Respect of Notice/s of Proposal’ and ‘RQIA’s Decision Making Panel (DMP) Procedures in Respect of Urgent Procedures’ for more information.

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    1. Introduction

    1.1. These procedures should be read as part of a suite of documents regarding enforcement action taken by RQIA that includes:

     RQIA Enforcement Policy (Document 1 in a Suite of 6)

     RQIA Enforcement Review Panel Procedures in Respect of Written Representation Regarding Improvement Notice/s (Document 3 in a Suite of 6)

     RQIA Enforcement Review Panel Procedures in Respect of Written Representation Regarding Failure to Comply Notice/s (Document 4 in a Suite of 6)

     RQIA Decision Making Panel Procedures in Respect of Notices of Proposal (Document 5 in a Suite of 6)

     RQIA Decision Making Panel Procedures in Respect of Urgent Procedures (Document 6 in a Suite of 6)

    1.2. These procedures should be read in conjunction with other relevant RQIA

    policies and procedures. A suite of templates has been developed for guidance purposes only.

    2. Principles

    2.1. Enforcement activity taken by RQIA will be in line with RQIA’s Enforcement Policy and the principles of good regulation outlined by the Better Regulation Task Force (Principles of Good Regulation), Cabinet Office Publication, (October 2003) and Regulators’ Code, Better Regulation Delivery Office (April 2014).

    3. The Legislative Framework

    3.1. In accordance with Article 12 of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 (2003 Order), any person who carries on or manages an establishment or agency without being registered under Part III of the 2003 Order shall be guilty of an offence.

    3.2. All registered establishments and agencies are required to comply with the 2003 Order and the relevant regulations. The 2003 Order and the associated regulations are available on RQIA’s website.

    3.3. Registered Person/Trust’s Responsible Individual/s are required to ensure that their establishment/agency/trust provide a standard of care and service in accordance with the Department of Health, Social Services and Public Safety (DHSSPS) standards. A list of relevant standards is available on RQIA’s website.

    3.4. RQIA may take a range of enforcement actions at the same time, provided each action clearly identifies the separate failures to comply with regulations and/or standards.

    3.5. RQIA may seek to prosecute in conjunction

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